Background: Postlaminectomy pain syndrome (PLPS), also referred to as failed back surgery syndrome, represents a complex clinical entity characterized by persistent or recurrent lower back pain, with or without radicular symptoms, following spinal surgery. Despite advancements in surgical techniques, the management of PLPS remains challenging due to its multifactorial and heterogeneous etiologies. Aim: This study aimed to evaluate the efficacy of posterior lumbar interbody fusion (PLIF) in improving clinical and radiologic outcomes for patients with PLPS due to surgically correctable structural causes. Methods: A retrospective study was conducted on 64 patients (mean age: 48.2 years, range: 34–75 years) who underwent PLIF by a single surgeon from 2014 to 2018. Clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain and Japanese Orthopaedic Association (JOA) scores. Radiologic evaluation included flexion/extension X-rays to determine fusion rates. Patients were followed up for a mean of 3.5 years (range: 2–6 years). Results: VAS scores improved from a preoperative mean of 8.5–1.9 at the final follow-up, while JOA scores increased from 9.3 to 23.1 (P < 0.001). The mean recovery rate was 79.1%, with a fusion rate of 88.7%. Complications included dural tears in 9.3% of cases, with no nerve root injuries. Satisfactory outcomes were reported in 79.7% of patients. Conclusion: PLIF is a safe and effective revision procedure for PLPS, offering substantial improvements in pain, function, and spinal stability. Its versatility makes it a viable option for addressing diverse structural causes of PLPS.

Background/Purpose: Orthopaedic Trauma Association (OTA) C-type distal femoral fractures can be very challenging to treat effectively. While locked plating is widely used in the complex distal femoral fracture, failure of locked plate fixation is not uncommon. First, we tried to determine the risk factor related to early failure of multiplanar OTA C-type fracture in the distal femur after fixation with lateral locked plate. Second, we tried to provide a strategy for surgeons to prevent pitfalls of early failure in the complex distal femoral fractures treated with lateral locked plating. Methods: We retrospectively reviewed 44 adults with OTA C-type fractures of the distal femur treated with locked plate fixation between 2010 and 2016 at Tri-Service General Hospital. Average length of follow-up was 27.6 months (range, 12-54 months). Univariate and multivariate logistic regression were used to determine the association of variables on early failure of fixation. A p-value < 0.05 in univariate and multivariate analyses were considered significant. Results: There were six patients experiencing early failure, and the early failure rate was 13.6%. The risk factors associated with early failure of complex distal femoral fracture identified by univariate analysis included sagittal oblique fracture pattern, longer working length and post-operative sagittal malalignment (odds ratio [OR] and 95% confidence intervals [CI]: 90.00 (6.85-1183.33), 0.55 (0.31-0.98) and 8.63 (1.077-69.075) respectively). The multivariate analysis showed only sagittal oblique fracture pattern was associated with early failure [OR: 52.348 (3.06-895.23)]. Conclusion: Sagittal oblique fracture was more likely to result in early postoperative failure. Early recognition of the fracture pattern should be considered to avoid catastrophic results. Copyright (C) 2020, Formosan Medical Association. Published by Elsevier Taiwan LLC.

Unilateral patellar tendon ruptures are a common complication that can occur frequently among athletic patients below the age of 40; however, bilateral spontaneous patellar tendon ruptures are rare and still not fully understood. We present a case of bilateral patellar tendon rupture in a 37-year-old patient with a history of systemic lupus erythematosus (SLE) who had concomitant chronic renal failure. Primary repair utilizing the Krackow interlocking stitch technique provided excellent outcomes in both knees. This case highlights the rare occurrence of spontaneous bilateral patellar tendon rupture in patients with SLE and chronic renal failure.

Background and Purpose. Hip dislocation combined with acetabular fracture remains a challenging condition for orthopedic surgeons. In this study, we utilized a computer-assisted simulation and three-dimensional (3D) printing technology to treat patients with hip dislocation combined with acetabular fracture. We hypothesized that the 3D printing-assisted method would shorten the internal fixation time and surgical time. Methods. We retrospectively reviewed 16 patients diagnosed with traumatic posterior dislocation of hip combined with acetabular fractures and treated with plate fixation from September 2013 to August 2017. Patients were divided into two groups: (1) traditional method and (2) 3D printing groups. In the traditional method group, the plates were contoured during the surgery, whereas in the 3D printing group, the patient's pelvic computed tomography image was transformed to the 3D medical image software for processing preoperatively. The fracture reduction was simulated by the computer. Thereafter, the 1:1 scale 3D printing model was used to design the surgical plan and contour patient-specific plates preoperatively. Results. The internal fixation time was significantly shorter in the 3D printing group than in the traditional method group (-33 min, P<0.05). The mean operative time was shorter than that in the traditional method group (-43 min). However, blood loss and postoperative radiograph results were similar between the groups. The complication rate was lower in the 3D printing group (2/7) than in the traditional method group (5/9). Interpretation. Computer-assisted simulation with 3D printing technology is a more efficient method for treating hip dislocation combined with acetabular fractures.

OBJECTIVE:Bone marrow-derived mesenchymal stem cells (BMSCs) have multilineage differentiation potential, which allows them to progress to osteogenesis, adipogenesis, and chondrogenesis. An imbalance of differentiation between osteogenesis and adipogenesis will result in pathologic conditions inside the bone. This type of imbalance is also one of the pathological findings in osteonecrosis of the femoral head (ONFH). Chicken ovalbumin upstream promoter-transcription factor II (COUP-TFII) was previously reported to mediate the differentiation of mesenchymal stem cells. This study investigated the expression of the osteogenesis regulator Runx2, osteocalcin, the adipogenesis regulator PPARγ, and COUP-TFII in the femoral head tissue harvested from ONFH patients, and characterized the effect of COUP-TFII on the differentiation of primary BMSCs.METHODS:Thirty patients with ONFH were recruited and separated into 3 groups: the trauma-, steroid- and alcohol-induced ONFH groups (10 patients each). Bone specimens were harvested from patients who underwent hip arthroplasty, and another 10 specimens were harvested from femoral neck fracture patients as the control group. Expression of the osteogenesis regulator Runx2, osteocalcin, the adipogenesis regulator PPARγ, C/EBP-α, and COUP-TFII was analyzed by Western blotting. Primary bone marrow mesenchymal cells were harvested from ONFH cells treated with COUP-TFII RNA interference to evaluate the effect of COUP-TFII on MSCs.RESULTS:ONFH patients had significantly increased expression of the adipogenesis regulator PPARγ and C/EBP-α and decreased expression of the osteogenesis regulator osteocalcin. ONFH bone tissue also revealed higher COUP-TFII expression. Immunohistochemical staining displayed strong COUP-TFII immunoreactivity adjacent to osteonecrotic trabecular bone. Increased COUP-TFII expression in the bone tissue correlated with increased PPARγ and decreased osteocalcin expression. Knockdown of COUP-TFII with siRNA in BMSCs reduced adipogenesis and increased osteogenesis in mesenchymal cells.CONCLUSION:Increased COUP-TFII expression mediates the imbalance of BMSC differentiation and progression to ONFH in patients. This study might reveal a new target in the treatment of ONFH.

Spontaneous regression of an osteochondroma of the distal femur is unusual. This report highlights the spontaneous regression of a sessile osteochondroma of the distal femur in a 9-year-old boy which resolved over a 4-year period. The mechanism underlying regression of the tumor is discussed with a review of previous reports. Since this type of osteochondroma can spontaneously resolve, conservative treatment is always the first choice to avoid unnecessary surgery.

Purpose: Fractures of the distal femur remain challenging to treat, and numerous fixation methods are designed to promote stability and fracture healing. Locking plate constructs have recently become the mainstream fixation method, but debate exists on whether to use locking plates alone or to augment them with interfragmentary screws. This article compares outcomes of distal femur fractures treated with a single locking plate alone versus those treated with a locking plate and interfragmentary screws. Methods: We retrospectively reviewed 57 patients treated for distal femur fractures from 2010 to 2013. Patients were divided into two groups: Those treated with a locking plate alone utilizing the minimally invasive plate osteosynthesis (MIPO) technique and those treated with combination of a locking plate and interfragmentary screws using an open technique. Postoperative outcomes were obtained via a manual chart review. Fracture healing and callus indices were evaluated from radiographs. Results: 9 patients required revision surgery in the locking plate alone group (6 for persistent nonunion and 3 for varus deformity). Only two patients in the combination group required revisions (both for nonunion). Average time to full weight bearing was 19.54 weeks in the locking plate group versus 14.57 weeks in the combination group (p = 0.004). At the time of full weight bearing, frontal (1.15 versus 1.11, p = 0.004) and sagittal (1.22 versus 1.15, P = 0.008) callus indices were both significantly greater in the locking plate group. Conclusions: In this study, the combination of a locking plate and interfragmentary screws achieved suitable stability and a faster time to full weight bearing than using a locking plate alone. Surgeons should consider combining a locking plate with interfragmentary screws as an effective method for fixation of distal femur fractures, particularly in cases when plate fixation alone fails to provide adequate fracture stability.

A method of closed reduction and internal fixation with cannulated screws was proposed as a surgical treatment of midshaft clavicle fractures. However, there are no mechanical studies about the cannulated screw used in the fixation of midshaft clavicle fracture. We conducted this study to compare the construct bending stiffness of a fixation midshaft clavicle fracture with a Knowles pin, cannulated screw and reconstruction plate. In addition, purchase lengths of both intramedullary devices were measured. After transverse osteotomy over the midpoint for fracture simulation, eighteen synthetic clavicles were assigned to 3 groups and fixed with reconstruction plate, Knowles pin or cannulated screw. Purchase length was defined as the engaged length of the intramedullary portion of the two intramedullary devices Stiffness, yield load and maximum load of the cantilever bending test were calculated of each tested synthetic bones. The Knowles pin group had a significantly longer average intramedullary purchase length compared with that of the cannulated screw group. The construct stiffness in the reconstruction plate group (5.6 ± 0.9 N/mm) was higher than that of the intramedullary devices; the Knowles pin group (3.1 ± 0.6 N/mm) provided a greater construct stiffness than did the cannulated screw group (1.7 ± 0.4 N/mm) (p = 0.007). The cannulated screw group had the lowest yield and maximum load compared with the reconstruction plate and Knowles pin groups. Both the reconstruction plate and Knowles pin failed at the implant-bone interface. However, the cannulated screw group failed at the osteotomy site with broken implants. This study suggests that fixation of midshaft clavicle fractures with cannulated screws may lead to early failure due to inadequate mechanical strength. Ideal intramedullary clavicle devices should supply adequate intramedullary purchase lengths and mechanical strength.

Surgical treatment of acetabular fractures with plate fixation is challenging for orthopaedic surgeons because of variations of the surface curvature and complex fracture patterns of the acetabulum. We present our experience with pre-operative computer-assisted virtual simulation and three-dimensional (3D) printing techniques for the surgical treatment of acetabular fractures, especially in terms of operative time and surgical outcomes.

Background: Pelvic ring injuries constitute only 2 to 8% of all fractures; however, they occur in 20% of polytrauma patients. High-energy pelvic fractures often result in mechanical instability of the pelvic ring. Successful treatment of unstable pelvic ring fractures remains a challenge for orthopedic surgeons. This study presents a novel internal fixation method for stabilizing unstable anterior pelvic ring fractures using a minimally invasive modified pedicle screw-rod fixation (MPSRF) technique. Methods: This retrospective study included six patients with unstable pelvic ring injuries who underwent MPSRF, with or without posterior fixation. Intraoperative parameters such as blood loss, operative time, complications, and quality of reduction (Matta criteria) were recorded and evaluated by a blinded reviewer. Results: In the present clinical series, the mean operative times and mean blood loss for unilateral versus bilateral anterior ring fixations were 176.0 min versus 295.6 min, and 153.3 mL versus 550.0 mL, respectively. No iatrogenic neuropraxia of the lateral femoral cutaneous nerve or femoral nerve palsy occurred. The reduction quality, graded by the Matta criteria, was excellent in five patients and good in one patient. Conclusions: There were no infections, delayed unions, nonunions, or loss of reductions during the follow-up period. Only one patient suffered from a broken rod at 4 months postoperatively. The modified technique represents a novel, minimally invasive procedure for the treatment of anterior pelvic ring fractures and offers a reliable and effective alternative to currently available surgical techniques.

PURPOSE:Treating pelvic fractures remains a challenging task for orthopaedic surgeons. We aimed to evaluate the feasibility, accuracy, and effectiveness of three-dimensional (3D) printing technology and computer-assisted virtual surgery for pre-operative planning in anterior ring fractures of the pelvis. We hypothesized that using 3D printing models would reduce operation time and significantly improve the surgical outcomes of pelvic fracture repair. METHODS:We retrospectively reviewed the records of 30 patients with pelvic fractures treated by anterior pelvic fixation with locking plates (14 patients, conventional locking plate fixation; 16 patients, pre-operative virtual simulation with 3D, printing-assisted, pre-contoured, locking plate fixation). We compared operative time, instrumentation time, blood loss, and post-surgical residual displacements, as evaluated on X-ray films, among groups. Statistical analyses evaluated significant differences between the groups for each of these variables. RESULTS:The patients treated with the virtual simulation and 3D printing-assisted technique had significantly shorter internal fixation times, shorter surgery duration, and less blood loss (- 57 minutes, - 70 minutes, and - 274 ml, respectively; P < 0.05) than patients in the conventional surgery group. However, the post-operative radiological result was similar between groups (P > 0.05). The complication rate was less in the 3D printing group (1/16 patients) than in the conventional surgery group (3/14 patients). CONCLUSION:The 3D simulation and printing technique is an effective and reliable method for treating anterior pelvic ring fractures. With precise pre-operative planning and accurate execution of the procedures, this time-saving approach can provide a more personalized treatment plan, allowing for a safer orthopaedic surgery.

The ideal treatment for comminuted intraarticular calcaneal fractures is still debated. Open reduction and internal fixation (ORIF) is the most popular surgical procedure; however, wound complications, implant choice, and infection remain major concerns. This study aimed to demonstrate the results of an innovative, minimally invasive surgical procedure, namely, a closed reduction technique using large-diameter Steinmann pins and percutaneous calcaneoplasty using injectable calcium sulfate cement (MIIG X3, Wright Medical Technology, Inc., Arlington, TN), in patients with comminuted calcaneal fractures.

Subtle injuries of the Lisfranc joint complex are uncommon and difficult to diagnose clinically and thus are easily missed even by experienced orthopedic doctors. Misdiagnosed injuries can lead to chronic disability until eventual fusion surgery. We describe 10 cases diagnosed with subtle injury of the Lisfranc joint that were treated with combined innovative portal arthroscopy and fluoroscopy-assisted reduction and percutaneous screw fixation in an interfragmentary fashion. The distance between the first and second metatarsals (the Lisfranc distance) and that between the medial cuneiform and fifth metatarsal base (foot arch height) was measured before and after surgery. The American Orthopaedic Foot and Ankle Society function score was evaluated perioperatively. The average preoperative and postoperative Lisfranc distance was 4.38 ± 0.39 mm and 2.68 ± 0.9 mm, the foot arch height was 12.63 ± 2.75 mm and 21.80 ± 3.50 mm, and the American Orthopaedic Foot and Ankle Society score was 59.1 ± 5.69 and 86.8 ± 10.1, respectively. Of the 10 patients, 3 had excellent outcomes, 6 had good outcomes, and 1 had a fair outcome. In conclusion, we report a useful and minimally invasive surgery for acute, subacute, and even chronic subtle injury of the Lisfranc joint. The Lisfranc distance, foot arch height, and function of the foot were restored clinically, and all measurements showed statistically significant differences.

In this case report, we describe a rare clinical situation of acute arterial thoracic outlet syndrome (TOS) after osteosynthesis, using an intramedullary Knowles pin, to treat nonunion of a midshaft clavicular fracture. Existing evidence was reviewed to appraise the relationship between TOS and nonunion of clavicular fractures, including the timing of the development of this complication, as well as to identify the relationship between surgical technique and choice of implant and the occurrence of TOS. Perioperative measures used to prevent TOS were identified.

To compare the recurrence risk of parameniscal cysts between arthroscopic meniscectomy with open cystectomy (arthroscopic excision) and entirely arthroscopic techniques with intra-articular cyst decompression (arthroscopic decompression).

Profunda femoris artery (PFA) injury is a rare complication following fracture of the femoral neck. Here, we present a case of a patient with an injured branch of the PFA following internal fixation with cannulated hip screws for a femoral neck fracture. Computed tomography angiography revealed active bleeding from the ascending and descending branches of lateral femoral circumflex artery. We suspected that the cause of the vessel laceration was the sharp tip of the guidewire used during surgery or the closed reduction performed during surgery. The patient was successfully treated with coil embolization. With early recognition and prompt radiological intervention, this rare complication following fracture fixation surgery can be treated without the need for additional surgery.

The combination of iliopsoas tendon impingement and snapping hip syndrome with persistent hip pain is rare in patients following total hip replacement (THR). Diagnosis should be made by clinical physical examination, with the exclusion of complications following THR by imaging or laboratory studies. Accurate diagnosis and adequate treatment can result in an excellent outcome and patient satisfaction. Hip arthroscopy can resolve both iliopsoas tendon impingement and snapping hip syndrome with minimally invasive surgery, immediate improvement, and rapid recovery.

Background: Pauwels classification has long been used in femoral neck fracture to measure the inclination of the fracture line and is still widely used. In recent years, however, some studies have contested the reliability of this measurement method. This study investigates modified measurement method to assess the inclination angle with assisted parameters to evaluate the correlation between the different angles and the incidences of loss of reduction, nonunion and avascular necrosis.Patients and methods: A retrospective study was conducted to analyse the clinical data of 209 relatively young patients (between 20 and 60 years old) with intracapsular femoral neck fracture fixed by inverted triangular screws between January 2004 and December 2010, including 111 males and 98 females, with an average age of 47.08 +/- 9.93 years. Using the modified measurement method, the pre-operative inclination angles of patients with intracapsular femoral neck fracture were analyzed. The measured angles were classified into three types: type I, <30 degrees; type II, 30-50 degrees; and type III, >50 degrees.Results: With regard to loss of reduction, nonunion and avascular necrosis, there were no significant differences with respect to age, sex and fracture side. However, there were significant differences with respect to fracture type, reduction quality and different modified Pauwels types. In the multiple regression analysis, the factors associated with loss of reduction were the fracture type (odds ratio [OR] = 7.22), reduction quality (anatomic vs unacceptable reduction, OR = 0.11; acceptable vs unacceptable reduction, OR = 0.23), and modified Pauwels type (type II vs type III, OR = 0.36). The factors associated with fracture nonunion were the fracture type (OR = 9.43), reduction quality (acceptable vs unacceptable reduction, OR = 0.17) and modified Pauwels type (type II vs type III, OR = 0.22). And the factors associated with avascular necrosis were the modified Pauwels type (type I vs type III, OR = 0.15; type II vs type III, OR = 0.36).Conclusions: A displaced fracture, poor reduction quality and high modified Pauwels type are noted risk factors for loss of reduction and fracture nonunion in the post-operative follow up of intracapsular femoral neck fracture. The modified Pauwels type is also noted a risk factor for avascular necrosis. Thus, this modified method is a useful tool for correcting the deficiencies of traditional Pauwels classification and predicting the outcome of femoral neck fractures. (C) 2015 Elsevier Ltd. All rights reserved.

We report on a 17-year-old man who underwent prophylactic fixation of the incomplete subtrochanteric femur fracture produced by a low-velocity gunshot. The subtrochanteric region is a high-stress site. Therefore, to avoid progression to complete fracture and displacement requiring secondary surgical stabilization, we used a proximal femoral nail for prophylactic fixation of the incomplete subtrochanteric femur fracture. The patient was able to walk and bear weight on the injured side immediately after surgery. At the 1-year follow-up, the patient was pain-free with a full range of motion of his right hip and had a bony union.